Family Medicine: A dying breed, or a lifeline for U.S. healthcare?

I think a lot of national leaders in family medicine are pondering this very question right now. Just check out the discussion around the future of family medicine in the “Family Medicine for America’s Health” campaign. Here’s the link to a special issu

I believe the U.S. healthcare system is broken. I also believe that, unfortunately, family medicine, as a specialty, is in crisis. To fix the healthcare system, we need integrated, comprehensive, coordinated, high-quality, evidence-based, and safe care provided to all. The payment system for healthcare must be revolutionized to make such care delivery possible. Fee-for-service needs to be abolished. It needs to be replaced by a national health program that provides universal coverage for all. We need clinicians and clinics who not only provide excellent care for the patients who show up in our exam rooms, but that reach out to those who don’t and develop plans for taking care of them, as well. We need clinicians and clinics who also look beyond the healthcare needs of their patient panels and work to improve the health and well being of whole communities.

I firmly believe that providing such care was part of the original vision of family medicine when it was founded as a specialty nearly 50 years ago. The crisis we face is that, after living for two generations in a specialist-dominated, fee-for-service world, our comprehensivist, whole-person perspective has been eroded. We still train family medicine residents to provide comprehensive care; however, market pressure drives them into limited-scope practices. Our residents leave our programs to take on high-paying jobs that do not use much of what we teach in family medicine residency – no inpatient medicine, no call, no pediatric care, no obstetrical care, no gynecologic care, and no procedures. American Academy of Family Physician and American Board of Family Medicine surveys report that about 65% of FPs do not do office gynecology; 50% do no pediatrics; 80% do no office procedures; 60% do no inpatient; and some 93% do no obstetrics.

I’m not arguing that every family physician needs to “do it all.” The breadth of medical knowledge and skill sets needed to provide such comprehensive service is too vast for any one clinician. What I am saying is that a family medicine practice should provide such comprehensive care, which means that their should be clinicians in that practice who provide women’s health services, obstetrics, see children, do procedures, and take care of patients who are hospitalized. Our crisis is that – the way things are going – such practices won’t exist. Moreover, graduates of our residency programs have to replace not only the aging physicians in the community, but they must replace the equally aging population of academic family physicians. Will they teach future generations of family physicians to provide comprehensive care if they, themselves, have chosen not to do so?

Bottom line: Unless there is a dramatic and fundamental shift in the direction that family medicine is headed, I believe it will die as a specialty within the next generation.

Pretty grim statement. However, I do think there’s hope. Current economic realities make the argument for comprehensive primary care more compelling. Employers, state and federal governments, and insurers are reeling from the astronomical and unsustainable costs of health care. I think the time is right for pushing for payment reform in healthcare. Campaigning for payment reform needs to be our number one priority.

So, to answer the question in the headline of this post, here’s my list of critical initiatives family medicine practices should be taking in the next 2-to-5 years to become a lifeline for U.S. healthcare:

Join with others in campaigning for payment reform (pay for comprehensive, coordinated care)

Build team-based, comprehensive practices that provide wrap-around service to children, adults, men, and women – including obstetrical and procedural care

Develop programs to improve the health of our patients with chronic illnesses – not only for those who come to clinic, but for all those under our care

Collaborate with other sectors in the community – such as health departments, schools, businesses, local government, and community organizations – to improve the health and well being of the entire community

Ensure that gains in health and well being occur for all, i.e., work to reduce or eliminate health inequities